Provider Demographics
NPI:1760560809
Name:IC MED SUPPLY INC
Entity Type:Organization
Organization Name:IC MED SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-733-3333
Mailing Address - Street 1:5730 BOWDEN RD
Mailing Address - Street 2:STE 103
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6104
Mailing Address - Country:US
Mailing Address - Phone:904-733-3333
Mailing Address - Fax:800-732-0860
Practice Address - Street 1:5730 BOWDEN RD
Practice Address - Street 2:STE 103
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6104
Practice Address - Country:US
Practice Address - Phone:904-733-3333
Practice Address - Fax:800-732-0860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5727400001Medicare NSC